Meckel's diverticulum is a congenital anomaly found in approximately 2% of the general population. The complications caused by Meckel's diverticulum include intussusception, volvulus in adolescents and acute bleeding in adults 3. This is an interesting and unusual case of spontaneous perforation of Meckel's diverticulum, in a Caucasian woman.A 46-year-old Caucasian woman was admitted because of severe abdominal pain and diarrhoea. A CT (Fig. 1) scan of the abdomen and pelvis was obtained, which demonstrated free air and a moderate amount of free fluid in the pelvis tracking up the gutters. The patient was consented and taken to theatre for diagnostic laparoscopy. A normal appendix was identified during laparoscopic examination of the abdomen. An inflammatory mass was seen with turbid fluid collection in the pelvic area on laparoscopy. The inflammatory mass turned out to be a perforated Meckel's diverticulum (Fig. 2). Wedge resection of the perforated Meckel's diverticulum was performed with endoGIA stapler fired at the base of diverticulum. Histopathology showed heterotopic gastric mucosa within the diverticulum and evidence of acute inflammation with perforation. The patient was followed up for two years and is symptom-free.The total lifetime rate of complications is widely accepted at 4%, with a male-to female ratio ranging from 1.8:1 to 3:1 4,5. Hemorrhage is the most common presentation in children and is reported in over 50% of cases 10. In adults, hemorrhage occurs often but only in 11.8% is present 5. 90% of bleeding diverticula contain heterotropic mucosa, most often gastric mucosa 13. In one study, 11% of children with complicated Meckel's diverticulum (MD) were initially diagnosed with appendicitis.8The diagnosis of ruptured MD was ultimately made by laparoscopy. This case demonstrates that a healthy degree of suspicion for complicated MD should be present when dealing with a questionable diagnosis of appendicitis. Laparoscopy has a definite role in patients with symptomatic Meckel's diverticulum, especially when the diagnosis is in doubt and it has proved definitive in facilitating diagnosis. KEY WORDS: Gastric mucosa, Heterotropic mucosa, Merkel's diverticulum.

Torsion of the vermiform appendix is a rarely observed acute abdominal emergency. The clinical manifestations are similar to acute appendicitis. It should be included in the differential diagnosis if a patient presents with intermittent abdominal pain and an acute abdominal emergency. Here, we describe a 4-year-old male patient with a mass located in the right lower abdominal quadrant, whose clinical findings were consistent with an acute abdomen. The gangrenous appendix was found in the pelvic cavity and its stump was twisted clockwise. A 1.5-cm fecalith was detected in the appendix lumen and appendectomy was performed.

Lower back pain (LBP) is a widespread, expensive, and debilitating problem in Western industrialized countries. Though LBP can be caused by acute injuries, biomechanical discrepancies have also been indicated to cause chronic LBP. A possible link between podiatrical deviations and LBP has been established in the literature; yet, no comprehensive review investigating the effects of foot and ankle deviations on low back pain has been published. The aim of this study was to assess the relevant literature concerning the effects of foot and ankle deviations on LBP. After review, it was determined that there is limited research regarding ankle and foot deviations and their connection to LBP. Reviewed studies have linked flat feet, ankle instability, sagittal plane blockage and excessive pronation to LBP. Specifically, excessive pronation has been shown to cause leg length discrepancies leading to pelvic tilts and LBP. Based on these results, ankle and foot deviations can be considered a potential cause for LBP due to the disruption of the kinetic chain from the foot to the back. Clinicians should consider the foot and ankle when addressing LBP, especially if more conventional etiologies fail to describe the condition.

This paper describes a case of ovarian metastasis from lung carcinoma along with its diagnostic challenges, clinical management, and review of the literature. A 49-year-old woman was admitted to our emergency department with complaints of abdominal pain and vomiting. A laparoscopic appendectomy was performed due to acute appendicitis, and a unilateral oophorectomy (left side) via laparoscopy was performed due to the detection of an ovarian mass. Immunohistochemical staining of the ovarian mass revealed that it was reactive to cytokeratin-7 (CK-7) but negative for CK-20. The immunohistochemical and pathological features of the tumor indicated an ovarian metastasis of non-small-cell lung cancer. The patient underwent chemotherapy and was followed up by the oncology department. Her postoperative regular followup of 6 months showed that her condition was stable with no recurrence. The management of female patients with acute abdominal pain and pelvic masses should consist of a multidisciplinary approach to include the diagnosis of any distant organ metastasis.

Diagnostic accuracy of first-line sonographic evaluation by obstetrics/gynecology residents in determining the need for emergency surgery in women with acute pelvic pain is unknown. Aim of this study was to evaluate the diagnostic accuracy of routine ultrasound evaluation by obstetrics/gynecology residents, available 24 hours a day, in patients with acute pelvic pain.A cross-sectional retrospective study included consecutive patients who underwent emergency laparoscopy for acute pelvic pain at a teaching hospital gynecologic emergency unit, between January 1, 2004, and December 31, 2006. The laparoscopic diagnosis was the reference standard. Gynecologic and nongynecologic conditions requiring immediate surgery to avoid severe morbidity or death were defined as surgical emergencies. In all patients, obstetrics/gynecology residents routinely performed clinical examination and standardized ultrasonography was routinely recorded. Sonograms were re-interpreted for the study, blinded to physical examination and laparoscopic findings, according to evidence-based predetermined criteria. Sensitivity, specificity, and likelihood ratios were computed for clinical data alone, sonographic data alone, and the combination of both.Emergency laparoscopy was performed in 234 patients, diagnosing 139 (59%) surgical emergencies. Clinical and sonographic examinations performed by the residents each independently predicted a need for emergency surgery. Combining both examinations was superior over each examination alone and had an acceptable false-negative rate of 1%.First-line combined clinical and sonographic examination by obstetrics/gynecology residents is effective in ruling out surgical emergencies in patients with acute pelvic pain.

BACKGROUND:

Pelvic inflammatory disease (PID) is a polymicrobial infection that typically occurs in sexually active females. PID is rare in premenarchal and/or noncoital young women; however, there are case reports of PID occurring in virginal females. We present the first reported case of PID associated with F. nucleatum. In this unusual case of PID in an adolescent, the responsible organism may have originated from the patient's oral cavity. CASE: A 13-year-old noncoital Caucasian female presented to a tertiary children's hospital with fever and acute abdominal/pelvic pain. She had experienced a perforated appendix 14 months prior, which was treated by laparoscopy. Postoperatively, she experienced intermittent episodes of recurrent abdominal pain. During this presentation, the physical examination and ultrasound findings were suspicious for an ovarian torsion. She was taken to the operating room where she had an examination under anesthesia and a diagnostic laparoscopy. Findings at the time of laparoscopy were in keeping with a diagnosis of pelvic inflammatory disease. Oral and pelvic fluid cultures were positive for F. nucleatum. She was subsequently treated with antibiotics and her symptoms resolved. SUMMARY AND

CONCLUSION:

This case highlights the importance of including PID in the differential diagnosis of noncoital adolescent females presenting with an acute abdomen. Although most Fusobacteria infections are periodontal in nature, translocated infections to the pelvis may have long-term implications for reproductive health. This case also highlights the importance of the role of diagnostic laparoscopy in young women who have persistent pain following previous surgery due to the potential of missed pathology or subclinical infection.

Cytomegalovirus (CMV) infection in immunocompetent hosts is generally asymptomatic or may present as a mononucleosic syndrome. Its association with acute cervicitis and vulvovaginitis has rarely been reported. A 24-year-old woman presented with pelvic pain, vulvodynia, abnormal vaginal discharge, burning with urination, fatigue, fever, vomiting and diarrhoea. The vulva and cervix were red with vesicular lesions on the cervix. Genital herpes simplex infection (HSV) was suspected and valacyclovir was given orally. However, serial viral cultures performed 7 weeks apart did not isolate HSV as suspected, but CMV was confirmed by immunofluorescence and early antigen research. Blood tests confirmed an acute CMV infection. Typical inclusions were found at histology. Symptoms resolved slowly with persistence of cervical lesions at 7 weeks from diagnosis. The frequency of CMV genital infection is probably underestimated. The infection is not always asymptomatic and might be confused with genital HSV infection. The clinical course is longer.

The most frequent symptom with leiomyoma is menometrorrhagia. However, it can be responsible of pelvic pain, dysmenorrhea or urinary and digestive compression when it is particularly voluminous. If no therapy is able to have them disappear, various drugs may reduce their related symptoms. Tranexamic acid, non-steroidal anti-inflammatory drugs and high dose of oestrogen may be useful in the management of acute hemorrhagic disorders. Progestin, such as lynestrenol induces small reduction in leiomyoma volume and moderate increase in hemoglobin level before surgery. Pregnane and nor-pregnane may improve menstrual bleeding in short or mild delays. The use of GnRH agonists can reduce menstrual bleeding with hemoglobin recovery. Add-back therapy using tibolone seems interesting since secondary effects encountered with GnRH agonists may be reduced. Levonorgestrel-releasing intrauterine system is proven to reduce increased menstrual bleeding and restore hemoglobin level. Aminoglutethimide and fadrozole have been underevaluated to conclude when letrozole seems as efficient as GnRH agonists to reduce leiomyoma volume and provide less hotflushes. Anastrozol is associated with reduction in leiomyomata volume, pain and menstrual bleeding. Mifepristone reduces the size of uterine leiomyomata, improves symptomatology, but could be associated with development of endometrial hyperplasia. SPRM evaluated in females have shown to improve leiomyoma related symptomatology. Ulipristal could be useful to reduce leiomyoma related symptoms in short terms.

Adult ureteroceles are generally known as simple ureteroceles with minimal obstructive effects 1 that can usually be managed endoscopically. Such pathology presented with acute abdominal pain and fever in a 32-year-old man with left renal agenesia, a cranial blind left ureter and left obstructed ureterocele. The retained secretions were suppurative.

PURPOSE:

To review the etiology and pathogenesis of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).

METHODS:

A literature review for the years 1985-2012 was performed using the MEDLINE database of the United States National Library of Medicine.

RESULTS:

The evidence for ongoing infection in men with CP/CPPS is lacking. However, men with CP/CPPS are twice as likely to have had a sexually transmitted disease (STD), and bacteria from men with CP/CPPS may be phenotypically different from those that cause cystitis or acute prostatitis. Evidence continues to support an alteration in both the afferent and efferent autonomic nervous systems. Functional brain imaging suggests changes in the gray matter as well as the importance of the anterior insula and anterior cingulated gyrus in pain processing. Neural function can be modulated by immune and endocrine factors. Alterations in cytokine function and autoimmunity appear to play a role in the immune dysfunction. Alterations in the hypothalamic-pituitary-adrenal axis can mediate the endocrine effects, similar to many other chronic pain conditions. Genetics may play a role in who may develop chronic pain after an initial insult. Finally, any biological changes must then be processed through the psychosocial environment, including the tendency to catastrophize, and degree of spousal support, to produce a given individual patient's pain experience.

CONCLUSIONS:

Infection with atypical bacteria or sequelae of an STD may lead to CP/CPPS in some men. Such a biological insult in the context of alterations in psychoimmunoneurendocrine factors produces the chronic pain experience.